Reconsidering isolation precautions for endemic methicillin-resistant Staphylococcus aureus and vancomycin-resistant Enterococcus

Discontinuing MRSA and VRE contact precautions: Defining hospital characteristics and infection prevention practices predicting safe de-escalation

OBJECTIVE

To define conditions in which contact precautions can be safely discontinued for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE).

DESIGN

Interrupted time series.

SETTING

15 acute-care hospitals.

PARTICIPANTS

Inpatients.

INTERVENTION

Contact precautions for endemic MRSA and VRE were discontinued in 12 intervention hospitals and continued at 3 nonintervention hospitals. Rates of MRSA and VRE healthcare-associated infections (HAIs) were collected for 12 months before and after. Trends in HAI rates were analyzed using Poisson regression. To predict conditions when contact precautions may be safely discontinued, selected baseline hospital characteristics and infection prevention practices were correlated with HAI rate changes, stratified by hospital.

RESULTS

Aggregated HAI rates from intervention hospitals before and after discontinuation of contact precautions were 0.14 and 0.15 MRSA HAI per 1,000 patient days (P = .74), 0.05 and 0.05 VRE HAI per 1,000 patient days (P = .96), and 0.04 and 0.04 MRSA laboratory-identified (LabID) events per 100 admissions (P = .57). No statistically significant rate changes occurred between intervention and non-intervention hospitals. All successful hospitals had low baseline MRSA and VRE HAI rates and high hand hygiene adherence. We observed no correlations between rate changes after discontinuation and the assessed hospital characteristics and infection prevention factors, but the rate improved with higher proportion of semiprivate rooms (P = .04).

CONCLUSIONS

Discontinuing contact precautions for MRSA/VRE did not result in increased HAI rates, suggesting that contact precautions can be safely removed from diverse hospitals, including community hospitals and those with lower proportions of private rooms. Good hand hygiene and low baseline HAI rates may be conditions permissive of safe removal of contact precautions.

Antimicrobial Resistance Patterns of Bacterial and Fungal Isolates in COVID-19

Background: The pattern of bacterial infection in coronavirus disease 2019 (COVID-19) patients differ worldwide. Objectives: This study aimed to determine the patterns of bacterial infections and the antibiotic resistance profile by VITEK 2 (bioMérieux, France) in the culture of blood samples from hospitalized patients with COVID-19. Methods: This retrospective descriptive cross-sectional was conducted on a total of 25 patients with critical COVID-19 admitted to Imam Reza Hospital in Mashhad, Iran, during the first three COVID-19 peaks (2019 - 2020). Results: Among Gram-positive bacteria, two strains isolated from Staphylococcus aureus were methicillin-resistant S. aureus at a concentration of > 2 μg/mL. Enterococcus was vancomycin-resistant Enterococcus at a concentration of higher than 4 μg/mL (the minimum inhibitory concentration [MIC] ≥ 32). Among Gram-negative bacteria, three strains of Acinetobacter baumannii complex were extensively drug-resistant. Conclusions: There is evidence of the remarkable increase of various antibiotics’ MIC during the COVID-19 pandemic, which highlights the impact of the use of steroids on the risk of developing antimicrobial resistance during the COVID-19 pandemic.

Long-term impact of contact precautions cessation for Methicillin-Resistant Staphylococcus Aureus (MRSA)

BACKGROUND

Methicillin-Resistant Staphylococcus aureus (MRSA) is a major cause of healthcare-associated infections (HAI). Contact isolation has been traditionally implemented to stop transmission but its impact is increasingly questioned.

METHODS

A single center, retrospective, nonrandomized, observational, quasi-experimental study compared MRSA HAI rates between pre-/postdiscontinuation of MRSA contact isolation in a tertiary university hospital over 68 months. Data on primary outcomes, Central line-associated bloodstream infections and MRSA LabID bacteremia events, were analyzed by interrupted time series design using segmented Poisson regression modeling. As secondary outcomes catheter-associated urinary tract infections , ventilator-associated pneumonia , surgical site infections and hospital-associated pneumonia were compared using Fisher's exact tests. Current savings due to discontinuation were calculated based on gown use.

RESULTS

Two hundred and ninty-five patients developed 399 HAIs. Infection rates between pre- and postinterventions were as follows: Central line-associated bloodstream infections: (0.02% vs 0.02%; P-value = .64), MRSA LabID events: (0.01% vs 0.02%; P-value = .32), hospital-associated pneumonia: (0.01% vs 0.01%; P-value = .64), catheter-associated urinary tract infections: (0% vs 0.01%; P-value = .56), ventilator-associated pneumonia: (0.01% vs 0.01%; P-value = .32), surgical site infections (0.55% vs 0.15%; P-value = .03). Savings amount to $139,228 annually.

CONCLUSIONS

Discontinuing CP did not negatively impact endemic MRSA HAI rates between pre-postdiscontinuation periods and saved costs for isolation materials.

Methicillin-Resistant Staphylococcus aureus: An Update on Prevention and Control in Acute Care Settings

Methicillin-resistant Staphylococcus aureus (MRSA) is a leading cause of health-care-associated infections. Controversies regarding the effectiveness of various control strategies have contributed to varying approaches to MRSA control. However, new evidence from large-scale studies has emerged, particularly concerning screening and decolonization. Importantly, implementation and outcomes of control measures in practice are not only influenced by scientific evidence, but also economic, administrative, and political factors, as demonstrated by decreasing MRSA rates in a number of countries after concerted and coordinated efforts at a national level. Flexibility to adapt measures based on local epidemiology and resources is essential for successful MRSA control.

Justice in control of methicillin-resistant Staphylococcus aureus transmission: a fair question to ask?

Active surveillance cultures and contact precautions is a strategy to control the transmission of methicillin-resistant Staphylococcus aureus (MRSA) within healthcare facilities. Whether to implement this strategy to routinely screen and isolate inpatients with MRSA in non-outbreak (endemic) settings, or to remove it and use standard infection control precautions only is scientifically and ethically controversial, in view of the potential adverse effects of contact precautions on patients. To support the use of standard precautions only, it has been argued that active surveillance to identify patients who are asymptomatically colonised with MRSA to place them in contact precautions is unjust or unfair to these patients in various ways. This paper will unpack and examine four distinct arguments, which are advanced from a medical ethics or quality improvement ethical framework, for why this is so. Our analysis shows that while these arguments highlight the injustice of current practices, they do not provide strong ethical reasons for justifying the removal of active surveillance and contact precautions to control MRSA transmission and infection. An implication of our arguments is that the ethical frame for evaluating prevention and control strategies for MRSA, a multi-drug resistant bacteria, should shift from healthcare to primarily public health. From a public health ethics perspective, whether a strategy is unjust, or how ethically significant its lack of fairness is, depends on assessing the evidence for its public health effectiveness and necessity in a given setting, and the extent of the harms and burdens patients with MRSA bear when they are on contact precautions, which remain matters of scientific debate or uncertainty. As an ethical consideration in the debate, the chief normative implication of justice is to provide us further reasons to revise current active surveillance-contact precautions practices, and for the need for research and interventions to minimise their potential adverse effects on patients.

The impact of vancomycin-resistant Enterococcus (VRE) screening policy change on the incidence of healthcare-associated VRE bacteremia

OBJECTIVE

To evaluate the impact of a vancomycin-resistant Enterococcus (VRE) screening policy change on the incidence of healthcare-associated (HA)-VRE bacteremia in an endemic hospital setting.

DESIGN

A quasi-experimental before-and-after study.

SETTING

A 1,989-bed tertiary-care referral center in Seoul, Republic of Korea.

METHODS

Since May 2010, our hospital has diminished VRE screening for admitted patients transferred from other healthcare facilities. We assessed the impact of this policy change on the incidence of HA-VRE bacteremia using segmented autoregression analysis of interrupted time series from January 2006 to December 2014 at the hospital and unit levels. In addition, we compared the molecular characteristics of VRE blood isolates collected before and after the screening policy change using multilocus sequence typing and pulsed-field gel electrophoresis.

RESULTS

After the VRE screening policy change, the incidence of hospital-wide HA-VRE bacteremia increased, although no significant changes of level or slope were observed. In addition, a significant slope change in the incidence of HA-VRE bacteremia (change in slope, 0.007; 95% CI, 0.001-0.013; P = .02) was observed in the hemato-oncology department. Molecular analysis revealed that various VRE sequence types appeared after the policy change and that clonally related strains became more predominant (increasing from 26.1% to 59.3%).

CONCLUSIONS

The incidence of HA-VRE bacteremia increased significantly after VRE screening policy change, and this increase was mainly driven by high-risk patient populations. When planning VRE control programs in hospitals, different approaches that consider risk for severe VRE infection in patients may be required.

Sustained fall in inpatient MRSA prevalence after a video-reflexive ethnography project; an observational study

BACKGROUND

Maintaining optimal infection prevention and control (IPC) in a busy, clinical environment is challenging. Video-reflexive ethnography (VRE) is a collaborative, interventionist approach to practice improvement. We hypothesised that giving clinicians opportunities to view and reflect on video footage of everyday ward activities would raise awareness of, and suggest strategies to reduce, pathogen transmission risks. We undertook a VRE project, between March and September 2013, in two tertiary hospital surgical wards, with persistently high methicillin resistant Staphylococcus aureus (MRSA) endemicity, despite previous IPC interventions.

METHODS

This study was a retrospective/prospective observational study, using interrupted time-series analyses, to assess the effects of the VRE project on hand hygiene compliance, inpatient MRSA infections (newly infected patients, per 1000 occupied bed days) and inpatient MRSA colonisation prevalence, measured by serial point prevalence surveys. Follow-up continued until June 2016.

RESULTS

The VRE project was associated with changes in IPC behaviour and outcomes. Hand hygiene compliance increased (from 62% to 75%; p < 0.0001) and MRSA colonisation prevalence decreased significantly, in both wards (baseline 42%; average post-VRE 12%; p=<0.0001), MRSA infection rate decreased in one ward. Interpretation of results was complicated by a potential confounding effect of unplanned environmental hydrogen peroxide decontamination (HPD). Improved hand hygiene compliance was a predicted outcome of VRE, but also a potential contributor to reduced MRSA transmission.

CONCLUSION

Separate contributions of VRE (the intervention), HPD and hand hygiene compliance were uncertain, but their combined effect was significantly reduced MRSA endemicity, which previously had been resistant to attempted IPC interventions.

The Role of the Environment and Colonization in Healthcare-Associated Infections

Healthcare-associated infections (HAIs) can be caused by endogenous host microbial flora or by exogenous microbes, including those found in the hospital environment. Efforts to decrease endogenous pathogens via decolonization and skin antisepsis may decrease the risk of infection in some settings. Controlling the spread of potential pathogens from the environment requires meticulous attention to cleaning and disinfection practices. In addition to selection of the appropriate cleaning agent, use of tools that assess the adequacy of cleaning and addition of no-touch cleaning technology may decrease environmental contamination. Hand hygiene is also a critical component of preventing transmission of pathogens from the environment to patients via healthcare worker hands.

Mechanisms of fibronectin-binding protein A (FnBPA110-263) vaccine efficacy in Staphylococcus aureus sepsis versus skin infection

Increasing rates of life-threatening infections and decreasing susceptibility to antibiotics urge an effective vaccine targeting Staphylococcus aureus. Here we investigate the role of cellular immunity in FnBPA_110-263 mediated protection in Staphylococcus aureus infection. This study revealed FnBPA_110-263 broadly protected mice from seven FnBPA isotypes strains in the sepsis model. FnBPA_110-263 immunized B-cell deficient mice were protected against lethal challenge, while T-cell deficient mice were not. Reconstituting mice with FnBPA_110-263 specific CD4+ T-cells conferred antigen specific protection. In vitro assays indicated that isolated FnBPA_110-263 specific splenocytes from immunized mice produced abundant IL-17A. IL-17A deficient mice were not protected from a lethal challenge by FnBPA_110-263 vaccination. Moreover, neutralizing IL-17A, but not IFN-γ,reverses FnBPA_110-263-induced protective efficacy in sepsis and skin infection model. These findings suggest that IL-17A producing Th17 cells play an essential role in FnBPA_110-263 vaccine-mediated defense against S. aureus sepsis and skin infection in mice.

Noninfectious Hospital Adverse Events Decline After Elimination of Contact Precautions for MRSA and VRE

OBJECTIVETo evaluate the impact of discontinuing routine contact precautions (CP) for endemic methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) on hospital adverse events.DESIGNRetrospective, nonrandomized, observational, quasi-experimental study.SETTINGAcademic medical center with single-occupancy rooms.PARTICIPANTSInpatients.METHODSWe compared hospital reportable adverse events 1 year before and 1 year after discontinuation of routine CP for endemic MRSA and VRE (preintervention and postintervention periods, respectively). Throughout the preintervention period, daily chlorhexidine gluconate bathing was expanded to nearly all inpatients. Chart reviews were performed to identify which patients and events were associated with CP for MRSA/VRE in the preintervention period as well as the patients that would have met prior criteria for MRSA/VRE CP but were not isolated in the postintervention period. Adverse events during the 2 periods were compared using segmented and mixed-effects Poisson regression models.RESULTSThere were 24,732 admissions in the preintervention period and 25,536 in the postintervention period. Noninfectious adverse events (ie, postoperative respiratory failure, hemorrhage/hematoma, thrombosis, wound dehiscence, pressure ulcers, and falls or trauma) decreased by 19% (12.3 to 10.0 per 1,000 admissions, P=.022) from the preintervention to the postintervention period. There was no significant difference in the rate of infectious adverse events after CP discontinuation (20.7 to 19.4 per 1,000 admissions, P=.33). Patients with MRSA/VRE showed the largest reduction in noninfectious adverse events after CP discontinuation, with a 72% reduction (21.4 to 6.08 per 1,000 MRSA/VRE admissions; P<.001).CONCLUSIONAfter discontinuing routine CP for endemic MRSA/VRE, the rate of noninfectious adverse events declined, especially in patients who no longer required isolation. This suggests that elimination of CP may substantially reduce noninfectious adverse events.Infect Control Hosp Epidemiol 2018;788-796.

Regional Epidemiology of Methicillin-Resistant Staphylococcus aureus Among Adult Intensive Care Unit Patients Following State-Mandated Active Surveillance

Background

In 2007, Illinois became the first state in the United States to mandate active surveillance of methicillin-resistant Staphylococcus aureus (MRSA). The Illinois law applies to intensive care unit (ICU) patients; contact precautions are required for patients found to be MRSA colonized. However, the effectiveness of a legislated "search and isolate" approach to reduce MRSA burden among critically ill patients is uncertain. We evaluated whether the prevalence of MRSA colonization declined in the 5 years after the start of mandatory active surveillance.

Methods

All hospitals with an ICU having ≥10 beds in Chicago, Illinois, were eligible to participate in single-day serial point prevalence surveys. We assessed MRSA colonization among adult ICU patients present at time of survey using nasal and inguinal swab cultures. The primary outcome was region-wide MRSA colonization prevalence over time.

Results

All 25 eligible hospitals (51 ICUs) participated in serial point prevalence surveys over 8 survey periods (2008-2013). A total of 3909 adult ICU patients participated in the point prevalence surveys, with 432 (11.1%) found to be colonized with MRSA (95% confidence interval [CI], 10.1%-12.0%). The MRSA colonization prevalence among patients was unchanged during the study period; year-over-year relative risk for MRSA colonization was 0.97 (95% CI, .89-1.05; P = .48).

Conclusions

MRSA colonization prevalence among critically ill adult patients did not decline during the time period following legislatively mandated MRSA active surveillance. Our findings highlight the limits of legislated MRSA active surveillance as a strategy to reduce MRSA colonization burden among ICU patients.

Discontinuing contact precautions for multidrug-resistant organisms: A systematic literature review and meta-analysis

BACKGROUND

Several single-center studies have suggested that eliminating contact precautions (CPs) for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant enterococci (VRE) control in nonoutbreak settings has no impact on infection rates. We performed a systematic literature review and meta-analysis on the impact of discontinuing contact precautions in the acute care setting.

METHODS

We searched PubMed, CINAHL, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, and Embase through December 2016 for studies evaluating discontinuation of contact precautions for multidrug-resistant organisms. We used random-effect models to obtain pooled risk ratio estimates. Heterogeneity was evaluated with I² estimation and the Cochran Q statistic. Pooled risk ratios for MRSA and VRE were assessed separately.

RESULTS

Fourteen studies met inclusion criteria and were included in the final review. Six studies discontinued CPs for both MRSA and VRE, 3 for MRSA only, 2 for VRE only, 2 for extended-spectrum β-lactamase-producing Escherichia coli, and 1 for Clostridium difficile infection. When study results were pooled, there was a trend toward reduction of MRSA infection after discontinuing CPs (pooled risk ratio, 0.84; 95% confidence interval, 0.70-1.02; P = .07) and a statistically significant reduction in VRE infection (pooled risk ratio, 0.82; 95% confidence interval, 0.72-0.94; P = .005).

CONCLUSIONS

Discontinuation of CPs for MRSA and VRE has not been associated with increased infection rates.

Determinants of Implementation of Isolation Precautions Against Infections by Multidrug-Resistant Microorganisms: A Hospital-Based, Multicenter, Observational Study

OBJECTIVES

We aimed to ascertain the factors associated with lack of isolation precautions (IP) in patients infected or colonized by third-generation cephalosporin-resistantEnterobacteriaceae(3GCR-E) and methicillin-resistantStaphylococcus aureus(MRSA) in hospital settings.

DESIGN

Prospective surveillance and audit of practices.

SETTING

The study included 4 university hospitals in Lyon, France.

PARTICIPANTS

All patients hospitalized between April and June in 2013 and 2015 were included. Case patients had ≥1 clinical sample positive for MRSA and/or 3GCR-E.

METHODS

Factors associated with the lack of IP implementation were identified using multivariate logistic regression. The incidence of MDRO infections was expressed per 10,000 patient days.

RESULTS

Overall, 57,222 patients accounting for 192,234 patient days of hospitalization were included, and 635 (1.1%) MDRO cases were identified. MRSA incidence was 2.5 per 10,000 patient days (95% confidence interval [95% CI], 2.1–3.0) and 3GCR-E incidence was 10.1 per 10,000 patient days (95% CI, 9.2–11.0), with no crude difference between 2013 and 2015 (P=.15 andP=.11, respectively). Among 3GCR-E, the main species wereEscherichia coli(43.8%) andKlebsiella pneumoniae(31.0%). Isolation precautions were implemented in 78.5% of cases. Lack of IP implementation was independently associated with patient age, year, specialty, hospital, colonization compared with infection, and lack of medical prescription for IPs (adjusted odds ratio, 17.4; 95% CI, 8.5–35.8;P<.001).

CONCLUSIONS

MRSA and 3GCR-E infections and/or colonizations are frequent in healthcare settings, and IPs are implemented in most cases. When IPs are lacking, the main factor is the absence of medical prescription for IPs, underscoring the need for alerts to physicians by the microbiological laboratory and/or the infection control team.

Infect Control Hosp Epidemiol2017;38:1188–1195

Where is the difference between an epidemic and a high endemic level with respect to nosocomial infection control measures? An analysis based on the example of vancomycin-resistant Enterococcus faecium in hematology and oncology departments

Some infection control recommendations distinguish epidemic and endemic levels for infection control. However, it is often difficult to separate long lasting outbreaks from high endemic levels and it remains open, if this distinction is really useful. Aim: To compare infection control measures in endemic and epidemic outbreaks. Methods: The example of vancomycin-resistant Enterococcus faecium outbreaks in haematology or oncology departments was used to analyse differences in infection control measures between outbreaks and high endemic levels. The outbreak database and PubMed, including long lasting outbreaks, were used for this analysis. Two time limits were used for separation: 6 and 12 months. In addition, monoclonal and polyclonal outbreaks were distinguished. Findings: A total of 36 outbreaks were included. 13 outbreaks lasted 6 months or less, 9 outbreaks more than 6 months but at maximum 12 months and 9 more than 12 months. For the remaining outbreaks, no information about their duration was available. Altogether, 11 outbreaks were monoclonal and 20 polyclonal. Considering infection control measures, there were almost no differences between the different groups compared. Patient screening was given up in 37.5% of long lasting outbreaks (>12 months) and hand hygiene not reported in the majority of polyclonal outbreaks (77.8%). Conclusion: Despite many institutions trying to add further infection control measures in case of an outbreak, evidence based infection control measures should be implemented in endemic and epidemic situations. The crucial aspect is probably the degree of implementation and its control in both situations.

Prevention and Control of Methicillin-Resistant Staphylococcus aureus in Acute Care Settings

Methicillin-resistant Staphylococcus aureus (MRSA) is a leading cause of health care-associated infections worldwide. Controversies with regard to the effectiveness of various MRSA control strategies have contributed to varying approaches to the control of this pathogen in different settings. However, new evidence from large-scale studies has emerged, particularly with regards to MRSA screening and decolonization strategies, which will inform future control practices. The implementation as well as outcomes of control measures in the real world is not only influenced by scientific evidence but also depends on economic, administrative, governmental, and political influences.

Utility of nasal swab and age in detecting methicillin-resistant Staphylococcus aureus in pediatric head and neck abscesses

OBJECTIVE

To identify risk factors associated with the presence of methicillin-resistant Staphylococcus aureus (MRSA) in surgical cultures taken from incision and drainage (I&D) of head and neck abscesses in the pediatric population.

STUDY DESIGN

Retrospective case series.

METHODS

All patients under 18 years of age with a head and neck abscess requiring I&D from 2009 to 2015 were reviewed. MRSA nasal swab cultures were taken from all patients upon hospitalization. Surgical cultures were obtained from all patients and correlated with MRSA nasal swab results. Univariate and multivariate logistic regression was performed, and odds ratios (ORs) along with descriptive statistics were analyzed.

RESULTS

Of a total of 272 patients, there were 68 (25%) MRSA-positive abscesses. The majority (86.8%) of these abscesses were in children under 2 years of age. Overall, 12 (4.4%) presented with positive admission MRSA nasal swabs. Of these, 91.7% had MRSA-positive abscess cultures. Decreasing age in years showed an OR of 1.650 (P < 0.001) for MRSA-positive abscess, with children less than 1 year old having the highest OR of 10.74 (P < 0.001).

CONCLUSION

Younger age and MRSA nasal colonization were two statistically significant risk factors for developing an MRSA abscess of the head and neck. This study demonstrates a high positive predictive value for MRSA-positive neck abscesses when nasal swab screenings were MRSA-positive (91.7%). Children under 2 years of age-especially those under 1 year of age-or those with MRSA nasal colonization can be considered a high-risk population that may benefit from empiric antibiotics against MRSA for head and neck abscesses.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2407-2412, 2017.

A Dynamic Transmission Model to Evaluate the Effectiveness of Infection Control Strategies

BACKGROUND

The advancement of knowledge about control of antibiotic resistance depends on the rigorous evaluation of alternative intervention strategies. The STAR*ICU trial examined the effects of active surveillance and expanded barrier precautions on acquisition of methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) in intensive care units. We report a reanalyses of the STAR*ICU trial using a Bayesian transmission modeling framework.

METHODS

The data included admission and discharge times and surveillance test times and results. Markov chain Monte Carlo stochastic integration was used to estimate the transmission rate, importation, false negativity, and clearance separately for MRSA and VRE. The primary outcome was the intervention effect, which when less than (or greater than) zero, indicated a decreased (or increased) transmission rate attributable to the intervention.

RESULTS

The transmission rate increased in both arms from pre- to postintervention (by 20% and 26% for MRSA and VRE). The estimated intervention effect was 0.00 (95% confidence interval [CI], -0.57 to 0.56) for MRSA and 0.05 (95% CI, -0.39 to 0.48) for VRE. Compared with MRSA, VRE had a higher transmission rate (preintervention, 0.0069 vs 0.0039; postintervention, 0.0087 vs 0.0046), higher importation probability (0.22 vs 0.17), and a lower clearance rate per colonized patient-day (0.016 vs 0.035).

CONCLUSIONS

Transmission rates in the 2 treatment arms were statistically indistinguishable from the pre- to postintervention phase, consistent with the original analysis of the STAR*ICU trial. Our statistical framework was able to disentangle transmission from importation and account for imperfect testing. Epidemiological differences between VRE and MRSA were revealed.

Vancomycin-Resistant Enterococci: Epidemiology, Infection Prevention, and Control

Vancomycin-resistant enterococci (VRE) infections have acquired prominence as a leading cause of health care-associated infections. Understanding VRE epidemiology, transmission modes in health care settings, risk factors for colonization, and infection is essential to prevention and control of VRE infections. Infection control strategies are pivotal in management of VRE infections and should be based on patient characteristics, hospital needs, and available resources. Hand hygiene is basic to decrease acquisition of VRE. The effectiveness of surveillance and contact precautions is variable and controversial in endemic settings, but important during VRE outbreak investigations and control. Environmental cleaning, chlorhexidine bathing, and antimicrobial stewardship are vital in VRE prevention and control.

Elimination of Routine Contact Precautions for Endemic Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus: A Retrospective Quasi-Experimental Study

OBJECTIVE To evaluate the impact of discontinuation of contact precautions (CP) for methicillin-resistant Staphylococcus aureus (MRSA) and vancomycin-resistant Enterococcus (VRE) and expansion of chlorhexidine gluconate (CHG) use on the health system. DESIGN Retrospective, nonrandomized, observational, quasi-experimental study. SETTING Two California hospitals. PARTICIPANTS Inpatients. METHODS We compared hospital-wide laboratory-identified clinical culture rates (as a marker of healthcare-associated infections) 1 year before and after routine CP for endemic MRSA and VRE were discontinued and CHG bathing was expanded to all units. Culture data from patients and cost data on material utilization were collected. Nursing time spent donning personal protective equipment was assessed and quantified using time-driven activity-based costing. RESULTS Average positive culture rates before and after discontinuing CP were 0.40 and 0.32 cultures/100 admissions for MRSA (P=.09), and 0.48 and 0.40 cultures/100 admissions for VRE (P=.14). When combining isolation gown and CHG costs, the health system saved $643,776 in 1 year. Before the change, 28.5% intensive care unit and 19% medicine/surgery beds were on CP for MRSA/VRE. On the basis of average room entries and donning time, estimated nursing time spent donning personal protective equipment for MRSA/VRE before the change was 45,277 hours/year (estimated cost, $4.6 million). CONCLUSION Discontinuing routine CP for endemic MRSA and VRE did not result in increased rates of MRSA or VRE after 1 year. With cost savings on materials, decreased healthcare worker time, and no concomitant increase in possible infections, elimination of routine CP may add substantial value to inpatient care delivery. Infect Control Hosp Epidemiol 2016;1-8.

Reconsidering Contact Precautions for Endemic Methicillin-Resistant Staphylococcus aureus and Vancomycin-Resistant Enterococcus

BACKGROUND

Whether contact precautions (CP) are required to control the endemic transmission of methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant Enterococcus (VRE) in acute care hospitals is controversial in light of improvements in hand hygiene, MRSA decolonization, environmental cleaning and disinfection, fomite elimination, and chlorhexidine bathing.

OBJECTIVE

To provide a framework for decision making around use of CP for endemic MRSA and VRE based on a summary of evidence related to use of CP, including impact on patients and patient care processes, and current practices in use of CP for MRSA and VRE in US hospitals.

DESIGN

A literature review, a survey of Society for Healthcare Epidemiology of America Research Network members on use of CP, and a detailed examination of the experience of a convenience sample of hospitals not using CP for MRSA or VRE.

PARTICIPANTS

Hospital epidemiologists and infection prevention experts.

RESULTS

No high quality data support or reject use of CP for endemic MRSA or VRE. Our survey found more than 90% of responding hospitals currently use CP for MRSA and VRE, but approximately 60% are interested in using CP in a different manner. More than 30 US hospitals do not use CP for control of endemic MRSA or VRE.

CONCLUSIONS

Higher quality research on the benefits and harms of CP in the control of endemic MRSA and VRE is needed. Until more definitive data are available, the use of CP for endemic MRSA or VRE in acute care hospitals should be guided by local needs and resources.

Infect Control Hosp Epidemiol 2015;36(10):1163–1172